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COUNTY nlltchess
CITYfTOWN Wappin!)Ar
~~J:~CRT 1368 '
~5~~J~R 140
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ann ~m!Le GiacoPfmilJRuRNAME
-1
1. A. FUll. NAME
Mfu]~!3rd ~ticaRRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCiAl SECURITY NUMBER 101-60-9'361
2. RESIDENCE A. NV B. n, 'f"hSSS
lllTATE) 'jl::l5lJIfflj'
C. CHECK ONE 0 CITY I,;/! TOWN 0 VILLAGE
AND n hi, .
SPECIFY rougl'....eepile
D. STREET ADDRESS 1782 SOlltl1 Rd , Art 3Fl ZIP 1 ?FlQn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES li1l NO
3. A. AGE d9 3B. DATE OF BIRTH MO~ / rfJ~ / y1Q68
4. EMPLOYMENT
A. USUAL OCCUPATION 'lVarehoblse Manager
B. TYPE OF INDUSTRY OR BUSINESS P'lblishing
5. PLACE OF BIRTH ~R~~E~~~~~~ NtL'L)
6. FATHER
A. NAME P3l:J1 Stich
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Joanne Catherine Hintze
B. COUNTRY OF BIRTH I I S A
B. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE-.. ..... ..._...-.....GIVIL.ANNUlMENT
,A. NAME Joseph John Giacoponello
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME 1\4ar!)aret l\A::!ry TnrtnrAlli
B. COUNTRY OF BIRTH I I ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
. DIVORCE CIVIL ANNULMENT
DEATH
n
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE <::tich
(OPTIONAL. SEE REVERSEr
D. SOCIAL SECURITY NUMBER 1?0-FlA.-5R71
12. RESIDENCEA. NYSTATE) B. D~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND n bk .
SPECIFY rOllg eepsle
D. STREET ADDRESS 17R? ~n1lth Rei . Art ~5 ZIP 1 ?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ii"f NO
a~TH ~~AY -1 ~l~
13. A. AGE 33
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS RA::!r.nn r.~n
15. PLACE OF BIRTH Yonk"Arc:: NY
(CITY. STATE I c'oUNTRY IF NOT USI\)
16. FATHER
3B. DATE OF BIRTH
DEATH
o
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVOF!CED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
1ST
2ND
3AD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the m
21. SIGNATURE OF GROOM ~
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo State of ttie bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
o
o
o
o
o
o
o 0
o 0
o 0
o 0
legal impediment exis
22. SIGNATURE OF BRIDE~
by New York Domestic
w
en
z ~
~ { } NAME (PRINT)
::::; SEAL SIGNATURE ~
MAILING ADDRESS
'-v-I .
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
MONTH
YEAR
AM
06:06PM
11
08
2007
01
06 2008
STATE
27. TYPE OF CEREMONY
0)( RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Brol"'l X
C. LOCATION OF CEREMONY WO O~ I Q. Wn
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFYS+. Bo.roo,,'oo...<) ell u rch
40q E. 2.4Is;- S+. \ QY10
10 CIVIL
SIGNATURE ~
MAILING ADDRESS
l1 01 8o..rnes
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) M;
SIGNATURE~
DOH-98 (0312006)
N
STATE
31. WITNESS T
NAME (PRINT)
SIGNATURE~